Fear-Avoidance Beliefs and Clinical Outcomes for Patients Seeking Outpatient Physical Therapy for Musculoskeletal Pain Conditions

Abstract

Study Design Prospective cohort. Objective To investigate fear-avoidance eliefs across different anatomical regions for patients with musculoskeletal pain. Background Fear-avoidance beliefs were first widely studied in patients with low back pain. The early results of studies involving patients with cervical spine, knee, and shoulder disorders suggest that fear-avoidance beliefs have the potential to influence pain and function in different anatomical regions. However, very few prospective studies of fear-avoidance beliefs involve multiple anatomical regions. Methods The sample of this study consisted of 313 patients (mean age, 45.5 years; 115 males, 198 females) seeking outpatient physical therapy for cervical spine (n = 63), upper extremity (n = 58), lumbar spine (n = 79), or lower extremity (n = 113) complaints. During the intake session, patients completed the Fear-Avoidance Beliefs Questionnaire physical activity scale (FABQ-PA), modified for the appropriate anatomical location. Patients also rated pain intensity and function on the Therapeutic Associates Outcomes System (TAOS) Functional Index at intake and discharge. The collection of treatment-related parameters included the number of visits, calendar days of physical therapy, and treatment received. FABQ-PA scores were compared across anatomical regions. Elevated FABQ-PA scores and anatomical regions were also investigated for association with intake pain and function, clinical outcomes, and treatment utility parameters. Results Similar FABQ-PA levels were observed across the 4 anatomical regions (P>.05). Number of visits, calendar days of physical therapy, and treatment received did not differ between elevated and lower fear-avoidance belief levels (P>.05). Findings for pain intensity and function were similar for each anatomical region. Patients with elevated fear-avoidance beliefs had higher intake scores (P<.05), larger improvements (P<.05), but similar discharge scores (P>.05), compared to those with lower fear-avoidance beliefs. Conclusions These data suggest that, in patients with cervical, upper extremity, lumbar, or lower extremity complaints, fear-avoidance beliefs may have a similar influence on intake and change scores for pain intensity and function. General assessment of fear-avoidance beliefs using the FABQ-PA, especially to predict change scores, may be appropriate for use in patients with various musculoskeletal pain conditions. J Orthop Sports Phys Ther 2011;41(4):249–259, Epub 18 February 2011. doi:10.2519/jospt.2011.3488

Effect of Fear-Avoidance Beliefs of Physical Activities on a Model That Predicts Risk-Adjusted Functional Status Outcomes in Patients Treated for a Lumbar Spine Dysfunction

“…As summarized by George et al, 19 when using the complete FABQ-PA, there is evidence indicating that elevated fear-avoidance beliefs can be predictive of poor outcomes for patients with lumbar spine dysfunctions. 12,15,56 In addition, George and Stryker 18 reported that when dichotomizing patients of cervical, upper extremity, lumbar or lower extremity musculoskeletal pain using the psychometric methods described by Hart et al, 29 FABQ-PA was associated with functional outcomes, although patients with elevated FABQ-PA were associated with more functional change compared to those with not-elevated FABQ-PA. In our multivariable model, fear-avoidance added little to our understanding of FS outcomes, so we conducted a univariate analysis using the same data set.…”

“…Change in fear during therapy might prove a stronger predictor of FS outcomes compared to fear level at intake, as has been suggested. 62 Regardless of the FS outcomes measure, 15,18,25 assessing the level of fear-avoidance beliefs at initial evaluation for patients with lumbar spine dysfunctions seems warranted, particularly if evaluation results are used to develop targeted interventions that are used to assist in patient management for improved functional outcomes. Therefore, we recommend that clinicians use methods like the one described here to identify patients with elevated fearavoidance beliefs and decide whether to use targeted interventions for those with elevated fear.…”

“…Previous authors who have reported fear-avoidance beliefs as predictive have used different measures of FS. 15,18 Whether there is a specificity based on outcome measure used is unknown. Also, simply adding independent variables to the regression model should increase model predictive ability, so researchers and clinicians should strive to include the most clinically relevant variables in their models.…”

“…There is evidence that identifying patients with elevated fearavoidance beliefs and managing them accordingly may reduce fear and improve outcomes. [3][4][5][10][11][12][13][14][15][16][17][18][19][20]36,40,41,56,68 The purpose of this study was to determine the effect of adding a single-item screening variable that classified patients with elevated versus not elevated fearavoidance beliefs of physical activities on a model that predicts risk-adjusted FS outcomes.…”

The Effect of Training the Deep Cervical Flexors on Neck Pain, Neck Mobility, and Dizziness in a Patient With Chronic Nonspecific Neck Pain After Prolonged Bed Rest: A Case Report

“…The patient's fear of performing tasks and cervical movements was assessed using the Fear-Avoidance Beliefs Questionnaire (FABQ). 9,26,37 This questionnaire consists of 16 questions and focuses on pain-related fear of movement during physical activities (FABQPA) and work (FABQW). Although not as extensively documented, the FABQ has adequate psychometric properties.…”